• Performs timely, accurate, and complete resident assessments using. Re-assesses residents when appropriate and updates care plans when needed.
• Oversees management of and information involving resident assessments for case mix reimbursement and transmits MDS reports according to strict guidelines.
• Establishes and maintains a cyclical schedule and care planning process ensuring adherence to strict federal timelines.
• Coordinates interdisciplinary care plan meetings and conferences with Social Services, family members, and residents to encourage/facilitate family and/or resident participation and ensure positive resident outcomes including the attainment of the highest practicable physical, mental, and psychosocial well-being.
• Develops plans of care by eliciting input of staff and, to the extent practicable, the consent of the resident and/or resident’s interested family member, legal representative to include measurable objectives and timetables and accommodate resident’s needs and preferences including choices about preferred intensity of medical treatment.
• Maintains consistent and effective communication with clinical departments and other disciplines regarding resident admissions, schedule changes, as well as, resident change of condition and responses to interventions to facilitate suggestions of alternative approaches and revise and update plans of care to reflect progress towards goals.
• Actively participates during daily team meetings to ensure residents’ changes of condition are addressed while applying facility policy and procedure.
• Provides education to new, current, and clinical department staff to ensure accurate and up to date knowledge and care planning process.
• Conducts quality assessment and assurance activities, including regulatory compliance reviews to monitor performance and to continuously improve quality.
• Serves as a member of Quality Improvement committees to enhance positive resident outcomes.
• Collaborates with the Director of Nursing and Executive Director to ensure timely collection and delivery of requested data to the surveying agency representatives.
• Facilitates surveyor understanding of systems established.
• Assists in the development of corrective plans/actions as needed.
• Serves as part of the facility management team and provides input into facility global decision-making particularly as it relates to resident care situations.
• Assists the Director of Nursing in the daily functions of clinical services as directed by the Director of Nursing. This includes, but is not limited to, rotating weekend call, assisting with daily follow-through of resident change of condition reports, supervision of resident dining service, assisting with resident complaint investigation and resolution, investigation of abuse allegations, etc.
• Serves as manager in charge of facility in the absence of the Executive Director/Director of Nursing. Makes decisions and addresses issues throughout the building as they arise.
• Registered Nurse with health care experience in a long-term care facility
• Knowledge of RAI process required